Febrile neutropenia

Parents/carers are advised to telephone the unit if their child’s temperature is 38oC or above on one occasion, even if they appear well. Parents should also call if their child’s temperature is between 37.5^oC and 37.9^oC if they have any other concerns or symptoms. They are also instructed to contact the hospital if their child appears unwell, regardless of fever, and community professionals should note that low temperature may be a later sign of sepsis.  

Families / carers will be given advice over the phone as to what action to take following a Paediatric Haem / Onc Telephone Triage Assessment. This is a red, amber, green risk assessment tool used in most UK primary treatment centres (PTCs).

All families are advised to have a digital thermometer at home. 

Definition of neutropenia

Neutropenia is caused by systemic anti-cancer treatment or the disease itself. Neutrophils make up around 70% of our white blood cells and play a key role in fighting against bacterial infections. Therefore, when patients are neutropenic, they are at increased risk of serious infections. 

A child or young person is classed as neutropenic when their neutrophil count is less than 0.5 x10⁹/L 

Sometimes written as ANC < 0.5 x10⁹ cells/L (ANC=Absolute Neutrophil Count) 

Definition of febrile neutropenia

Febrile Neutropenia is defined as having a neutrophil count of less than 0.5 x10⁹/L and  a temperature of 38^oC or above on one occasion,  

or

other signs or symptoms consistent with clinically significant sepsis for example: rigor (shivers), sweating, pale, lethargic, cool hands or feet, fast breathing, fast heartbeat.  

Low temperatures < 36^oC may also indicate sepsis and the same guidelines should be followed as for febrile neutropenia.

Any unwell child or young person who is receiving or has recently received systemic anti-cancer treatment (chemotherapy, immunotherapy, targeted therapy, stem cell transplant) or radiotherapy should be considered at risk of infection even if afebrile (no temperature) and not neutropenic.

High temperature (fever) can be caused by the disease itself, infection, allergies and or reactions to medications. It is important to treat any fever as a sign of infection until it can be proven otherwise.    

Background

Febrile neutropenia is common in children and young people receiving cytotoxic chemotherapy for malignancy. Any child or young person (CYP) presenting with febrile neutropenia is at risk of neutropenic sepsis which is a potentially life-threatening condition if it is not managed quickly.  

Prompt and appropriate treatment must be started within one hour of temperature (if an inpatient) or one hour of arriving in hospital for review. Time of travel to hospital from onset of fever must be considered in giving advice about attending for review. Families must be made aware that children with fever who are unwell and immunocompromised may deteriorate rapidly and they can call 999 for assistance at any point on the journey.  

The risk and pattern of infection in patients with malignancy or other immunosuppressing condition depends on the primary diagnosis and the type, duration, and intensity of the treatment. The signs of infection may be minimal or absent in the presence of neutropenia or when patients are on steroids. Since there is no certain way of telling which febrile neutropenic patients have a potentially life-threatening infection, all such patients require investigation and empirical (based on concern) antibiotic therapy.  

Some or all of the following factors may be important:    

This category is not open to clinical staff directly involved in children and young people's cancer care e.g. in a paediatric or TYA principal treatment centre.

General risk factors

• Duration and severity of neutropenia - neutrophils <0.5x10⁹/L or rapidly falling neutrophil count
• Mucositis and gut toxicity due to systemic anti-cancer therapy or radiotherapy
• Radiotherapy
• Previously documented Pseudomonas aeruginosa
• Evidence of serious sepsis - hypotension, shock
• Aplastic anaemia with neutrophils  < 0.5 x 10⁹/L
• Autologous and allogeneic stem cell transplant recipients
• Chronic graft versus host disease
• Long term immunosuppressive treatment
• Receiving steroids as part of treatment
• In-dwelling Central Venous Access Device (CVAD), Peripherally inserted central catheter (PICC), Cerebral Spinal Fluid (CSF) access device, or other ‘foreign body,’ such as catheters or drains. 

Diseases linked to protocols which predispose to high risk febrile neutropenia

• Acute Myeloid Leukaemia (AML)
• Acute Lymphoblastic Leukaemia (ALL) in the first six months after diagnosis
• Relapsed AML or ALL
• Stage 4 Neuroblastoma
• B cell Non-Hodgkin Lymphoma / Burkitt Lymphoma

Initial treatment

Treatment is started immediately - as soon as a full blood count and blood cultures have been taken. Clinicians do not wait for the results of the full blood count or blood cultures to commence treatment with intravenous (IV) antibiotics 

Important information

Delays in detection and response to febrile neutropenia and sepsis can be life threatening and death is not an uncommon outcome.  

Research shows there are specific concerns with teenagers and young adults who will often delay reporting feeling unwell, or telling anyone they have a fever, to avoid hospital admission.  

Treatment should be started without delay even if the child or young person has no fever on presentation. Parental or patient report of a fever initiates treatment.

Do not perform rectal examination or administer rectal medications.

Revised Management of low-risk cases since 2020

The coronavirus pandemic prompted a review of the management of low-risk febrile neutropenia following a valid risk stratification tool, to;

Safely reduce the duration of admission

Safely reduce the duration of IV antibiotics

All patients with suspected febrile neutropenia must still attend hospital for review and receive a first dose of IV antibiotics within 60 minutes ^[1]. Some patients who meet the assessed eligibility criteria may now be considered for early discharge and oral antibiotics at home. This can only be assessed and managed via one of the UK designated Principal Treatment Centres or Paediatric Oncology Shared Care Units. ^[2] 

Page last updated: June 2025